Cause Of Hip Pain Research Articles

Inside Out: A Novel Labral Repair and Advancement Technique

Labral tears are a significant cause of hip pain and are currently the most common indication for hip arthroscopy. Compared with labral debridement, labral repair has significantly better outcomes in terms of both daily activities and athletic pursuits in the setting of femoral acetabular impingement. The techniques described in the literature all use anchor placement on the capsular aspect of the acetabular rim, which can be difficult especially anteriorly, where the rim is very thin, and has the potential for significant complications. Anchor breakage, anchor slippage into the surrounding (capsular side) soft tissue, and penetration of the cartilage surface are among the most common complications. We describe an intra-articular anchor placement technique for labral repair from inside out. This technique, because of the location of the anchor and direction of suture pull, can assist in labral advancement in cases in which the native labrum fails to create a seal because of its location away from the femoral head.

Time and Cost of Diagnosis for Symptomatic Femoroacetabular Impingement.

Background:Femoroacetabular impingement (FAI) and labral tears are common causes of hip pain that are often not promptly or properly diagnosed. To our knowledge, no reports have defined the time and cost of diagnosis of labral tears associated with FAI.Hypothesis:Patients with labral tears associated with FAI undergo extraneous diagnostic testing and pain and incur a significant amount of health care costs before they receive appropriate surgical management for their pathology.Study Design:Economic and decision analysis; Level of evidence, 4.Methods:A total of 78 patients diagnosed with symptomatic FAI were surveyed. A standardized questionnaire asked patients about time to diagnosis, symptoms, health care providers visited, imaging tests, and treatments prior to diagnosis. Costs were calculated based on 2012 national Medicare data.Results:Patients in the cohort saw an average of 4.0 health care providers, had an average of 3.4 diagnostic imaging tests, and tried an average of 3.1 treatments prior to diagnosis. The average total amount spent per patient prior to diagnosis was US$2456.97. The calculated minimum cost of diagnosis, including a visit to an orthopaedic surgeon as well as an anteroposterior pelvis and lateral hip radiograph and 1 magnetic resonance arthrogram, was US$690.62. The average duration between onset of symptoms and diagnosis of labral tear was 32.0 months.Conclusion:The average amount of health care dollars spent per patient prior to receiving a diagnosis of acetabular labral tear was US$1766.35 higher than the calculated minimum cost. This figure is based on Medicare payment amounts, which may significantly underestimate the actual charges at many hospitals, thereby increasing the total cost of diagnosis.Clinical Relevance:The costs and pain associated with this time, along with the potential long-term degradation of the hip joint, make it important for all health care professionals to recognize and appropriately manage or refer the patient.

Slipped Capital Femoral Epiphysis: Preventing and Managing Complications.

In nonmedical English parlance, a “slip” is a relatively benign event. But the term “slipped” in orthopaedics often describes a potentially serious condition, as in a slipped capital femoral epiphysis (SCFE). This usually backward slippage of the femur’s proximal epiphysis through the hypertrophic zone of the growth plate is one of the most common causes of hip pain in adolescents. Early detection and treatment of SCFE (typically with in situ screw fixation) is crucial because complications of the untreated condition are serious; they include osteonecrosis, chondrolysis, degenerative joint disease, chronic pain, and gait abnormalities. Bone destruction from SCFE is largely the result of blood-supply restrictions to the epiphysis, with subsequent articular cartilage damage occurring because of femoral head deformity. A case in the February 26 edition of JBJS Case Connector suggests that optimal treatment of osteonecrosis associated with SCFE may include hinged distraction after fixation. Madan and Maheshwari report on a ten-year-old girl who twisted her right leg while playing rugby. She continued to be weight-bearing on the leg for a few days, but then presented unable to bear weight. Radiographs revealed a severe SCFE, and she underwent an in situ single screw fixation within twenty-four hours of presentation, approximately one week after the onset of the initial symptoms. A postoperative radiograph revealed that the posteriorly positioned screw had exited the femoral neck and had penetrated the femoral head, putting the posterior retinacular vessels at risk. The authors first saw the patient at six weeks postinjury; three-phase computed tomography of both hips showed photopenia around the right femoral head …

Staged Management of Osteonecrosis with Open Reduction and Hinged Distraction After a Slipped Capital Femoral Epiphysis: A Case Report.

A slipped capital femoral epiphysis (SCFE) is most often seen in adolescents and can occur bilaterally in up to 25% of patients. It is the most common cause of hip pain in adolescence and is caused by weakness of the perichondrial ring and slippage of the proximal femoral epiphysis through the hypertrophic zone of the growth plate1. SCFE has an incidence of approximately two to three per 100,000 people2. Complications include osteonecrosis, chondrolysis, degenerative joint disease, chronic pain, gait abnormalities, and deformity3. We report a case of delayed presentation of SCFE following trauma, complicated by osteonecrosis. We managed this case with open reduction through the Ganz approach4 and internal fixation, followed by delayed hinged distraction with external fixation, achieving an excellent result. The patient and her parents were informed that data concerning the case would be submitted for publication, and they provided consent. A ten-year-old girl with a body-mass index of 21 twisted her right leg while playing rugby at school. She was able to bear weight immediately but had a limp. A few days later, the right leg gave way and she was unable to bear weight. She presented to the emergency room and was subsequently referred to the Trauma and Orthopaedics Department. Radiographs revealed a severe SCFE (Fig. 1). She underwent an in situ single screw fixation of the right SCFE within twenty-four hours of presentation (at approximately one week after the injury) (Fig. 2). Fig. 1 Initial radiograph on admission showing a severe right SCFE. Fig. 2 Fig. 2 Intraoperative image intensifier film of the in situ screw fixation. On postoperative radiographs, rather than being central, the position of the screw was mostly posterior. Computed tomography (CT) demonstrated that the screw, which was in the posterior half of the femoral head, had not …

The Prevalence of Radiographic Criteria of Femoral Acetabular Impingement in Patients Undergoing Hip Arthroplasty Surgery

Pistol grip deformity of the proximal femur has been reported as a potential cause of hip pain and early-onset arthritis. The exact incidence of patients with osteoarthritis resulting from femoral acetabular impingement (FAI) is unknown. The purpose of this study was to explore the relationship between radiographic markers of FAI in patients undergoing hip arthroplasty. We retrospectively reviewed the radiographs of patients undergoing hip arthroplasty by a single surgeon over a 2-year period. The patients were divided by age, those younger than 65 years and (group A) and those 65 years and older (group B). The radiographs were evaluated for morphology consistent with FAI including an α angle >55°, crossover sign, coxa profunda, acetabular protrusio, and ischial spine sign. Three independent reviewers evaluated all the radiographs. The incidence of CAM, Pincer, and mixed deformities were compared between the 2 groups. A total of 255 patients with 258 hip arthroplasties were included in this analysis. Group A was found to have a greater number of patients with CAM morphology. Linear regression analysis revealed that the α angle was greater in younger patients. Patients undergoing hip arthroplasty exhibit a high incidence of radiographic abnormalities consistent with FAI. The CAM-type morphology occurs more frequently in younger patients with advanced arthritis requiring hip arthroplasty. This morphology is thought to cause a delaminating injury to the cartilage of the acetabulum. This study supports the notion that CAM-type morphology is a risk factor for early development of degenerative arthritis of the hip.

Hip Pain in Children, a Diagnostic Challenge: Transient Synovitis or Septic Arthritis in Early Stage?

Differential diagnosis includes a wide spectrum of pathological conditions, some of which require urgent investigation and treatment. Trauma, Legg-CalvePerthes disease, Slipped Femoral Capital Epiphysis (SFCE), arthritis, transient synovitis, joint sepsis, osteomyelitis and rarely primary or metastatic bone tumors, may be the cause of hip pain in a limping child [1,2]. A prompt and accurate diagnosis is vital for the child’s health.

Bisphosphonate-induced periprosthetic fracture: a cause of painful total hip arthroplasty.

Background. Cases have been reported in the literature of periprosthetic fractures associated with the use of bisphosphonates occurring in the long term following a Total Hip Replacement (THR). We report an interesting case of periprosthetic fracture secondary to bisphosphonate use only a few months after a THR. Case Report. A 72-year-old lady (on bisphosphonates for 10 years) underwent a THR for osteoarthritis. She was pain-free in the first four months postoperatively. Thereafter, she developed spontaneous onset of pain in the lateral aspect of her thigh and groin and found it difficult to weight-bear. X-rays and blood tests were unremarkable. An ultrasound and MRI scan showed no evidence of effusion/collection or periprosthetic fracture. A radionuclide bone scan showed an abnormal appearance of the right femoral shaft. A subsequent CT scan showed an oblique vertical split on the anterior surface of the upper right femoral shaft. This stress fracture was managed nonoperatively with protected weight bearing. She has progressed well with good clinical and radiological signs of fracture healing. Conclusion. This case is an important addition to our knowledge that bisphosphonate-induced periprosthetic stress fractures can be a cause of hip pain only a few months following a THR.

Patient satisfaction after arthroscopic repair of acetabular labral tears.

BackgroundAcetabular labral tear is a main cause of hip pain and disability, often requiring surgical treatment. Improvements of hip arthroscopic technique have produced positive outcomes after labral repair with arthroscopy. The purpose of this study was to determine clinical outcomes and patient satisfaction after arthroscopic repair of acetabular labral tear.MethodsWe interviewed 21 patients (10 men and 11 women; mean age, 36 years [range, 22 to 57 years]) with acetabular labral tears that had been repaired arthroscopically in terms of satisfaction of the procedure. In addition, clinical outcome was assessed using visual analog scale (VAS) score, University of California, Los Angeles (UCLA) activity, Western Ontario and McMaster Universities (WOMAC) osteoarthritis index, and Harris hip score, and radiologic outcome was assessed using serial radiography. The patients were followed for 24-50 months.ResultsThe mean Harris hip score was 73 points (range, 64 to 84 points) preoperatively and 83 points (range, 66 to 95 points) postoperatively. Fifteen hips (71%) were rated excellent and good. The mean WOMAC osteoarthritis index and VAS scores were improved at final follow-up. UCLA activity at the latest follow-up improved in 16 patients. The Tonnis grade of osteoarthritis at the latest follow-up did not change in all patients. Eighteen of the patients (86%) were satisfied with the procedure.ConclusionsHigh rate of satisfaction after arthroscopic repair of acetabular labral tears is an encouraging outcome. Arthroscopic treatment of labral tears might be a useful technique in patients with hip pathologies, such as femoroacetabular impingement with labral tears.

Conservative Treatment of Femoroacetabular Impingement

Introduction: Femoroacetabular impingement (FAI) has recently been proposed as a cause of abnormal stress contact in the hip joint and as a major cause of hip pain in athletes from different sports. The main objectives of preoperative physiotherapy (PT) are pain relief, muscle strength gain and improved function.

What’s New in Femoroacetabular Impingement Surgery

Context:Femoroacetabular impingement (FAI) has been described as a common cause of hip pain in young adults. This leads to abnormal hip joint mechanics and contact pressures. The associated pathomechanics can lead to the development of early osteoarthritis. Better understanding of the anatomy and pathophysiology, biomechanics, and diagnostic and therapeutic advances has led to improved clinical outcomes. A growing body of evidence has set the foundation for future progress in the treatment of this commonly encountered condition.Evidence Acquisition:The PubMed database was searched for English-language articles pertaining to FAI over the past 15 years (1998-2013).Study Design:Retrospective literature review.Level of Evidence:Level 4.Results:The authors evaluated and discussed the current evidence regarding the anatomy, physiology, biomechanics, imaging, and clinical outcomes of surgical intervention for FAI. Based on this information, future directions for improving the diagnosis and management of FAI are proposed.Conclusion:There remains a diverse approach to the diagnosis and management of cam- and/or pincer-type FAI. Recent advances in clinical diagnosis, imaging, indications, and arthroscopic techniques have led to improved outcomes and have set the foundation for future progress in the management of this condition.Strength of Recommendation Taxonomy (SORT):B

HIP ARTHROSCOPY: WEST OF SCOTLAND EXPERIENCE

Hip arthroscopy has evolved over the last decade. There had been an increase in the demand for hip arthroscopies from patients and their general practitioners due to available information and...

What are athletes' perceptions of rehabilitation outcome 1 year after hip arthroscopy?

Hip arthroscopy is a minimally invasive surgical procedure. Femoroacetabular impingement (FAI) is being increasingly recognized as a cause of hip pain in athletes and is a growing indication for arthroscopic surgery. Few studies have attempted to address patient views on outcome after arthroscopy, and no qualitative studies have been carried out to date. To explore athletes' perceptions of rehabilitation outcome, the rehabilitative process, and return to sport and to gain insight into factors that affected this process. A retrospective qualitative approach was adopted using semistructured interviews. Eight eligible participants were interviewed. Each had been treated with hip arthroscopy for FAI from September to November 2010. Data were audiotaped, transcribed verbatim, and analyzed using thematic analysis. Three main themes emerged. (1) The ability to participate in sport; athletes were relatively satisfied with outcome despite some limitations in sporting ability. (2) Perceptions of hip problems; there was a lack of understanding and an association of hip problems with older people among the general public. (3) Athletes' perception of rehabilitation; athletes were dissatisfied with the rehabilitation and sought greater physiotherapy input. Overall, athletes were relatively satisfied with their outcome 1 y after hip arthroscopy, despite some having to adapt their sporting activities. Key areas that need to be addressed in future research include factors affecting outcomes of hip arthroscopy, longer-term outcomes, perception of FAI among the public and health practitioners, and the development of a standardized evidence-based rehabilitation protocol.

Arthroscopic Management of Protrusio Acetabuli

While technically difficult to perform, arthroscopic management of protrusio acetabuli may be a viable option for young patients with this diagnosis and no arthritis. The cause of hip pain and dysfunction in patients with protrusio acetabuli is unclear and debated. Whether it is the result of pincer-type impingement, medial joint overload, or medialization of the joint center there appears to be a consensus that this condition may be best treated with open surgical dislocation or joint arthroplasty. Thus the Purpose is to present the 4 year outcomes of a series of patients with protrusio acetabuli treated arthroscopically. Four hips in 3 patients, all active women, 26 – 37 years old with hip pain and radiographic evidence of protrusio acetabuli and center edge angle of 50 degrees or more were studied and followed for an average of 4 years (32 – 63 months). Each of these patients underwent arthroscopic anterior and lateral acetabuloplasty, partial labrectomy, synovectomy and chondroplasty. Follow up included evaluation with the modified Harris Hip Score (MHHS), radiographs, and clinical history and examination. At an average 4-year follow up, these patients were noted to have a reduction in their center edge angle of 8 degrees on average from 58 degrees (50 – 67) to 50 degrees (42 – 60) and marked improvements in their pain and function. Modified Harris Hip Score improved from an average of 54 (39.6 – 68) preoperatively to 97 (87 – 100) at final follow up. All three patients were happy with their outcomes. The one patient with degenerative changes on pre-operative radiographs (a 26 year old), was the only one with a score of less than 100 post-operatively. While technically difficult to perform, arthroscopic management of protrusio acetabuli may be a viable option for young patients with this diagnosis and no arthritis.

The Approach to the Evaluation and Surgical Treatment of Mechanical Hip Pain in the Young Patient

The mechanical causes of hip pain in a young athlete often reflect a complex combination of static and dynamic factors. A comprehensive diagnostic approach is paramount to the development of a rational treatment strategy that will address all underlying pathologic factors. The goals of this paper are to highlight the pertinent biomechanical factors of the hip joint in femoroacetabular impingement and to discuss the clinical history, physical examination, and radiographic findings that are essential to formulating a proper diagnosis and an effective treatment plan. In addition, the current literature and reported outcomes of femoroacetabular impingement surgery in athletic patients are reviewed.

Factors Associated With the Failure of Surgical Treatment for Femoroacetabular Impingement

Background: With the recent increased recognition of femoroacetabular impingement (FAI) as a cause of hip pain and early osteoarthritis, surgical treatment has proliferated. There is a growing body of literature on outcomes of surgical intervention for FAI, but factors associated with inferior surgical outcomes have not been reviewed systematically. Purpose: To review the available literature and identify factors associated with the failure of open or arthroscopic surgery for FAI. Study Design: Systematic review. Methods: Using the PubMed database, we searched for relevant English-language articles published from January 1966 through August 2012. Inclusion criteria were a primary focus on the surgical treatment of FAI, measurement of functional or pain outcomes, identification of treatment failures, and statistical analysis of factors leading to failure. Exclusion criteria were review articles, technique-only articles, and studies of nonoperative management. Two definitions of failure were considered: (1) a lack of statistically significant improvement in validated measures of pain, function, or satisfaction postoperatively; and (2) revision surgery or conversion to hip arthroplasty because of persistent symptoms. The consistency of association between preoperative variables and clinical outcomes was reported across all studies. Results: Thirteen studies were included. Three were retrospective; there were no randomized controlled trials. Many studies had important methodological limitations. Preoperative cartilage damage or osteoarthritis had the strongest and most consistent relationship with conversion to hip arthroplasty and with a lack of improvement in pain or function. Greater age at the index operation, worse preoperative modified Harris Hip Score, and longer duration of symptoms preoperatively (>1.5 years) were associated with conversion to hip arthroplasty. Conclusion: Older age, presence of arthritic changes, longer duration of symptoms, and worse preoperative pain and functional scores are associated with poor outcomes of surgery for FAI. Incorporation of these data into discussions with patients may facilitate informed, shared decision making about the surgical treatment of FAI.

Results of Arthroscopic Labral Reconstruction of the Hip in Elite Athletes

Background: Femoroacetabular impingement (FAI) has been well characterized as a cause of hip pain and resultant damage to the acetabular labrum. It has become increasingly clear that an intact labrum is essential for normal joint mechanics, hip stability, and preservation of the articular cartilage. Elite athletes with a hypoplastic or irreparable labrum present a difficult clinical challenge. Purpose: To assess clinical outcomes and determine if elite athletes are able to return to a high level of function and sport after labral reconstruction. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review of a prospectively collected registry identified 21 elite athletes (23 hips) with an average age of 28.0 years (range, 19-41 years) who underwent an arthroscopic iliotibial band labral reconstruction. Concomitant procedures included femoral and acetabular osteoplasty in all patients and microfracture in 9 of 23 hips. Clinical outcomes were assessed with the modified Harris Hip Score (MHHS), the Hip Outcome Score (HOS), the Short Form–12 (SF-12), and patient satisfaction (on a scale from 1-10). Return to play was determined, as well as level of return to play, based on sport-specific statistics. Results: Two patients progressed to arthroplasty. There were 2 revisions in this group of patients, both for lysis of capsulolabral adhesions in which the graft was found to be well integrated at the time of surgery. The rate of return to play was 85.7% (18/21), with 81% (17/21) returning to a similar level. Subjective follow-up was obtained from 17 of the remaining 19 patients (89%), with an average follow-up of 41.4 months (range, 20-74 months). The average MHHS improved from 67 to 84 (P = .026) and the average HOS Sport subscore from 56 to 77 (P = .009). The overall median patient satisfaction with outcome was 8.2 (range, 3-10). Conclusion: Arthroscopic labral reconstruction using an ipsilateral iliotibial band autograft provides good short-term clinical outcomes, high patient satisfaction, and a satisfactory level of return to play in a select group of elite athletes.

Molecular Characterization of Articular Cartilage from Young Adults with Femoroacetabular Impingement

Femoroacetabular impingement is a frequent cause of hip pain and may lead to secondary osteoarthritis, yet little is known about the molecular events linking mechanical hip impingement and articular cartilage degeneration. The first goal of this study was to quantify the expression of inflammatory cytokine and chemokine, matrix-degrading, and extracellular matrix genes in articular cartilage harvested from control hips and hips with femoroacetabular impingement and end-stage osteoarthritis. The second goal was to analyze the relative expression of these genes in articular cartilage harvested at various stages of osteoarthritis. Cartilage samples were obtained from thirty-two hips undergoing hip preservation surgery for femoroacetabular impingement or hip arthroplasty. Three control cartilage samples were also analyzed. Specimens were graded intraoperatively with regard to the severity of cartilage damage, the radiographic osteoarthritis grade was recorded, and quantitative RT-PCR (real-time polymerase chain reaction) was performed to determine relative gene expression. Except for interleukin-1β (IL-1β) and CXCL2, the mRNA (messenger RNA) expression of all other chemokine (IL-8, CXCL1, CXCL3, CXCL6, CCL3, and CCL3L1), matrix-degrading (matrix metalloproteinase [MMP]-13 and ADAMTS-4), and structural matrix (COL2A1 [collagen, type II, alpha] and ACAN [aggregan]) genes was higher overall in cartilage from hips with femoroacetabular impingement compared with hips with osteoarthritis and normal controls. The differences reached significance (p ≤ 0.05) for seven of these ten quantified genes, with CXCL3, CXCL6, and COL2A1 being elevated in the femoroacetabular impingement group compared with only the control group and IL-8, CCL3L1, ADAMTS-4, and ACAN being elevated compared with both the osteoarthritis and control groups. When samples were grouped according to the stage of the degenerative cascade, mRNA expression was relatively higher in one of the two middle stages of femoroacetabular impingement (chondromalacia or cleavage/thinning), with the difference reaching significance for IL-8, CXCL2, CXCL3, CCL3L1, and ACAN. ACAN expression was diminished in hips with osteoarthritis compared with femoroacetabular impingement but elevated compared with the control articular cartilage. Articular cartilage from the impingement zone of hips with femoroacetabular impingement (and particularly those hips in the cleavage/thinning stage) expressed higher levels of certain inflammatory, anabolic, and catabolic genes, representing a heightened metabolic state. The articular cartilage from the impingement zone of hips with femoroacetabular impingement was metabolically hyperactive, supporting the concept that such impingement is a structural precursor to hip osteoarthritis.

Femoroacetabular Impingement: Defining the Condition and its Role in the Pathophysiology of Osteoarthritis

Femoroacetabular impingement (FAI) is an increasingly recognized cause of hip pain. It is best defined as a pathologic mechanical process by which morphologic abnormalities of the acetabulum and/or femur combined with vigorous hip motion lead to repetitive collisions that damage the soft-tissue structures within the joint itself. Based on cross-sectional studies in which FAI morphology was studied before the presence of radiographic osteoarthritis (OA), and on prevalence studies in younger, asymptomatic persons, it is clear that FAI and its morphologic risk factors are common in young adult hips and predispose to the later development of OA in certain patients. Longitudinal studies also support the assertion that, in middle-aged adults, the presence of cam deformities at baseline substantially increases the risk of developing OA and the need for total hip arthroplasty. More long-term data are needed to better define the natural history of pincer deformities as well as FAI in younger cohorts.

Snapping Hip: Imaging and Treatment

Snapping hip, or coxa saltans, presents as an audible or palpable snapping that occurs around the hip during movement and can be associated with or without pain. The prevalence of snapping hip is estimated to occur in up to 10% of the general population, but it is especially seen in athletes such as dancers, soccer players, weight lifters, and runners. Although the snapping sound can be readily heard, the diagnostic cause may be a clinical challenge. The causes of snapping hip have been divided into two distinct categories: extra-articular and intra-articular. Extra-articular snapping hip can be further subdivided into external and internal causes. Advances in imaging techniques have improved the diagnostic accuracy of the various causes of snapping hip, mainly by providing real-time imaging evaluation of moving structures during the snapping phase. Image-guided treatments have also been useful in the diagnostic work-up of snapping hip given the complexity and multitude of causes of hip pain. We discuss the common and uncommon causes of snapping hip, the advanced imaging techniques that now give us a better understanding of the underlying mechanism, and an image-guided diagnostic and therapeutic algorithm that helps to identify surgical candidates.

Non-Femoroacetabular Impingement

Femoroacetabular impingement is one of the causes of hip pain leading to acetabular labral tears and cartilage damage that may lead to the development of early osteoarthritis. More recently other causes of impingement have been recognized that may be the culprit for the painful hip. These causes include ischiofemoral, anterior inferior iliac spine/subspine and iliopsoas impingement. Ischiofemoral impingement syndrome is related to narrowing between the ischial tuberosity and lesser trochanter with abnormalities of the quadratus femoris muscle producing hip pain. Anterior inferior iliac spine/subspine impingement syndrome is defined as hip pain produced by abnormal contact between the anterior inferior iliac spine and proximal femur. Iliopsoas impingement may produce hip pain that is related to a thickened or taut iliopsoas tendon at the level of the acetabular rim/anterior hip capsule. Radiographs, magnetic resonance imaging, ultrasound, or computed tomography may help to better elucidate the problem while excluding intra-articular pathology or femoroacetabular impingement. Keeping these causes of impingement in mind when evaluating the painful hip will aid in diagnosis.